Increasing Chlamydia and Gonorrhea Test of Re-infection Rates in a Large, Urban Student Health Center Using a Quality Im

1. Increasing Chlamydia and GonorrheaTest of Re-infection Rates in a Large, Urban Student Health Center Using a Quality Improvement Approach A Baby step approach to improvement in STD monitoring Susan Mancuso FNP/MSN University at Buffalo Buffalo, New York 716-829-3001 mancuso@buffalo.edu

2. Acknowledgements for valued assistance • Gale Burstein MD/MPH, Commissioner of Health Erie County Health Department/Buffalo, New York • Scott Zimmerman DrPH, MPH, director Erie County Public Health Laboratory and staff /Buffalo, New York • Heather Lindstrom PhD, former Director disease Surveillance Erie County Health Department/Buffalo, New York • Cicatelli Associates: Kelly Morrison Odoyke MPH and associates, Region 2 IPP • Staff at Health Services, University at Buffalo

3. University at Buffalo, Buffalo New York • Largest University in the State system • Population as of 2011: 29,461 students • 19,000 undergraduates/ 9,000 Graduates/ ~ 2000 in other campuses • 3 local campuses/ 1 international campus in Malaysia/1 campus NYC • Population of student body: variety ages/ USA and many International Health Services is located on South Campus (city) • Funded through student fees/ students must be insured as of 2010 • 11 providers: physicians (3 FT, 2 PT) and 6 FT Mid-levels (NP’s) • No fee services • Most common ICD codes used: sinusitis and sexual health related issues

4. Collaboration With Erie County Public Health Labs and Department for STD screening and testing at $10 cost to students • Started 2007……named “UB TESTED” • Became a WIN-WIN for both UB students, providers at Health Services and ECHD. • Began BABY STEP APPROACH in providing better STD services to student population…..started CQI protocols to improve STD screening on campus….

5. First Collaboration Study: looking at number tested and incidence of communicable disease in college age population • First CQI intervention for Communicable diseases at Health Services: using data from 6/2007 to 5/31/2009. Data compiled by the ECHD division of STD surveillance. 1366 were tested……. Characteristics of students tested in this pilot project: 58% tested were white, 18% Black, 12% Asian, 6% Hispanic, and 6% other or not declared. • For Chlamydia: the highest positive rate was in Black males <25 years of age. • 6.5% of positives were international students • 4.1% of positives were asymptomatic screens • 6.5% were CT, 0.4% GC, 0.3% syphilis and 0.4% Hepatitis C • No positive HIV, Hepatitis A or B were found Presented at 2010 CDC/STD conference – poster presentation “ High Chlamydia Prevalence Found in a Collaborative Health Department – University Student Health Services Sexually Transmitted Infection screening Program”: Lindstrom, Burstein, Mancuso and Zimmerman Oral Presentation 2009, ACHA AND NYSCHA annual meetings

6. What analysis of first CQI study revealed? • Analysis of ECHD data revealed a “tremendous flaw*” in Student Health Services reporting and treatment of Chlamydia and over testing of some diseases (low prevalence area). A. error in reporting and treatment a. 4 patients (all females) with + CT results were missed by providers but found in ECHD analysis of data** 1. 3 patients were found and treated but treatment occurred > 6 months after + CT report (in one situation 1 year after + report) 2. 1 patient was found but had graduated and had already been treated for PID (age 23) B. low incidence of Syphilis, Hepatitis A, B and C and HIV and over testing of low risk students…providers just checked boxes on ECPHL form! C. Leads to first CQI improvement………Phase 1….tracking of + results

7. University Health Services – EMR MEDICAT instituted 5/7/2009 which assisted in CQI evaluation: the “dawn of EMR at UB” Will EMR help us with TOR?

8. Start of Yearly Quality Improvement for STD Testing and Treatment at SHC - 5/7/2009 • Yearly updates – what’s new in STD testing, treatment and trends and tailoring of tests to risk presented by Medical Director ECHD STD clinic…. Start of Phase 1 CQI B. RN intervention: every positive communicable disease report or telephone call is given to RN or replacement if she is off. 1. Begin Excel: every positive Infectious Disease followed on spreadsheet by assigned RN. 2. RN - Completes/ faxes required ECHD case report form for Reportable diseases to ECHD (STD surveillance division). 3. RN - Makes sure student contacted/ treated/ referred if necessary….

9. Phase 1 Results: 5/7/09 to 7/12/10RN received all +CT/GC reports/calls/faxes-team effort 107+ CT and/or + GC cases were reviewed by Coordinator • Variables followed on Excel: Id#, DOB, sex/ethnicity, DOV, date of treatment, med used, provider, TOR and comments • Review of data: overview of what was found …………….revealedvery low TOR for CT and GC………………….. → only 30 actually came in for TOR in ideal timeframe of 90 days → 4 who came in for TOR were still + for CT → VERY WIDE RANGE FROM 10 DAYS TO >15 MONTHS for TOR follow-up! c. Positive findings → not one communicable disease was missed by providers, testing was correlated to disease risk and medical staff was updated on STD trends

10. Phase 1: Quality Improvement (Excel etc)Ideal Timeframe ≈ 90 days*

11. Phase 1: Who was retested (TOR) within 42-90 days? • Female gender: 47 of 59 (80%) were retested with only 15 of 59 (25%) tested within ideal timeframe • Male gender: 18 of 48 (38%) retested with only 6% retested within ideal timeframe Males represented 71% of students (30 of 42) who were not retested. Although, 65 were retested ONLY 30 came in for TOR…..35 came in only due to STD s/s! CDC RECOMMENDS 90 DAYS as ideal timeframe

12. Annual staff in-service by ECHD Medical director/STD surveillance: results of Phase 1 CQI presented to provider staff • Medical director encourages staff to develop a plan to increase TOR for CT/GC…leads to start of Phase 2. She reviewed and updated provider staff on guidelines recommended by CDC for ideal timeframe for CT/GC TOR: many not fully aware. • CDC recommends that providers should advise all patients with CT and/or GC to be retested in 3 months* or if 3 month follow-up is not possible whenever they seek care in the next 12 months. Note: 12 months later is too long in this population! It is an eternity to young adults - very transient population! b. Importance of not retesting prior to 21-24 days by NAAT reviewed • Discussed NYS Department of Health Family Planning low TOR results.

13. PHASE 2: CQI started to increase TOR rates for CT and/or GC at University Student Health Center Improved Baby step plan = Added to Phase 1: Emails to all + cases to be done by RN

14. Phase 2 plan outline • RN (who does Excel spreadsheet etc) will now send an Email reminder to all +CT/GC students to remind them to come in for TOR within 90 days – ………………….post cards eliminated as reminder option! • Data will be collected from start of Fall semester 2010 to last day of Spring 2011 semester than reviewed by Coordinator. • Medical Staff will only use NAAT after 21 days for those who return with persistent STI complaints. • Medical staff will emphasize to each + case the importance of TOR and risk of PID encouraging follow-up in ideal timeframe. • Medical staff will still continue to order labs based on risk.

15. Phase 2: CQI Improvement EMR review Summer 2011

16. Phase 2 - Who was tested within Ideal Timeframe(3 months) • Female gender: 17 of 30 (57%) retested 4 tested in ideal timeframe (13% ) • Male gender: 15 of 27 (56%) retested 5 tested in ideal timeframe (19%) ↑↑ significant increase in number of males retested in Phase 2 – leads to Phase 3 CQI….what was different? Is this important in increasing our TOR rates for both males and females? ↓ ? Is there a difference between female and male care at the clinic?

17. Overview of what record review revealed for Phase 2: 8/2/10 to 5/3/11 • Still tested too early (1) • Decreased TOR in ideal time frame (17% to 16%) • Still + cases (3/23) at TOR follow-up • Frustration of RN: in some cases especially “repeat offenders” she sent 3-5 Emails and got no response and no follow-up • Variability in how + cases were handled by 11 providers

18. Patients (3/23) who were still + for CT at TORin Phase 2! • Interviewed by coordinator • Not aware that if they vomited within 2 hours or got profuse diarrhea that they needed to call. b. Not aware to abstain from sex for 8 days after treatment for him/her and partner even if zithro used! c. Not aware that any partner, who he/she had had sex with in last 6 months, needed to be notified and treated or tested and treated (serial monogamy). • Not aware that you can get an STD prior placement of condom! “Not aware”: ALL ISSUES REVEAL A TRUE FAILURE IN MEDICAL STAFF PROPERLY INFORMING PATIENTS ON KEY POINTS RELATED TO STD EDUCATION – WHY?

19. Other patients who did not come in were contacted by coordinator (10) • Very difficult task to contact patients – found after a # months: no cell, not same cell number, cell no longer in service and not at UB anymore etc. • Those who were reached did admit to receiving RN reminder Email but they did not know who she was so did not open the Email (spam/virus/worm issue). • Had not been made aware by provider that TOR was VERY important-just suggested! • 5 had s/s again and had gone off campus for testing and treatment????

20. Comparison Phase 1 versus 2Ideal time ≈ 3months Phase 1- Excel only/provider education Phase 2 - Excel with RN e mail and provider re-education Number retested 1. % females 4 or 13%↓ 2. % males 27 or 56%↑ For both genders, 16% (9/57) retested in 42-90 days Significant improvement in male retesting! Number retested 1. % females 15 or 25% 2. % males 18 or 6% For both genders, only 17% (18/107) retested in 42-90 days

21. What was different between female and male treatment of +CT/GC in Phase 2? • All EMR Records of + cases were reviewed by coordinator • Some very different treatment plans found between the 11 providers • Male providers brought patient back in for discussion, patient given patient education booklet (CDC booklet) and discussed needs/issues regarding treatment and contacts “in person”. • Female providers discussed + result by phone contact and left script at reception or called script into local pharmacy: no “personal contact”. 1. only one female provider gave out any patient education booklet (CDC booklet). 2. no available open appointment time so phone call used????

22. Phase 3 starts due to findings from Phase 2 • Medical director of ECHD/STD services returned for yearly update with providers → • a. Coordinator advised Medical director of TOR results, comparing Phase 1 and Phase 2 (↓) • b. Coordinator asked ECPHD for assistance in formulating an improvement plan and identified the need after analyzing the data → • c. ECHD Medical director contacted Region 2 IPP (Cicatelli) for assistance: K. Morrison Odoyke MPH and Melissa Kyriakos Nelson MSc.

23. Summer of 2011 began “big baby steps” CQI improvements with Cicatelli assistance • Monthly group teleconferences with: • ECHD/STD Medical Director • ECHD/Epidemiology division • Coordinator at UB SHC • Director of SHC (at onset only) • Cicatelli Region 2 representatives • Coordinator explained how “department functioned” → Cicatelli analyzed data (Phase 1+2) • Various ways to improve TOR discussed in teleconference and Emails with team members. Many ideas discussed and reviewed on a monthly basis during summer 2011…… than every group brought their most important idea to the table!

24. Main concerns that were discussed by team • Focus groups? • Incentives? • EPT? • Educate so “not aware is not an issue” but in 15 minute appointment? How can we do this? • Is 55-90 days an ideal time frame for this age population? • How to remind them to f/u? texting, University assigned Email again, private Email contact, phone, or postcard??? • Follow-up appointment: should it be made at end of treatment appointment? EMR records this ……no show etc. • Should improved success with male follow-up in Phase 2 be an important factor?

25. Phase 3 plans Many ideas discussed and investigated over the summer, and statistical analysis of phase 1 and 2 was done by Cicatelli associates→ outcome allowed everyone to input “some one point that they thought was very important”.

26. Breakdown of Phase 3: changes implemented 8/2011 • RN – will still get all + reports/complete CRF etc from Phase 1 • Appointment - All patients MUST return to clinic if + report and no phone treatment or scripts called in! Any exceptions?.......... (Phase 2: males) • Treatment – everyone will get “free oral or IM medication”…incentive? • Education– patient education letter was written addressing key points from “not aware portion of Phase 2” and CDC booklets “Protect yourself and protect your partner” were ordered and given to providers to handout with EMR educational letter 1. letter is automatically in EMR/ downloading it records that provider gave it out written by Coordinator and designed by Cicatelli. ∙ Return – ideal timeframe changed by ECHD medical director now 25-55 days - (? better time frame for this transient population!). 1. Patients asked to make follow-up appointment when leaving for 6-8 weeks later and mark their blackberry. I Phone calendar.. 2. prompts automatic reminder and parking pass 3. No show issues

27. Phase 3 protocol continued: Coordinator takes over → receives completed + STD CRF from designated RN ↓ • Reviews every EMR progress note: was protocol followed? ↓ • Completes variables on Excel spreadsheet……(Phase 1 continued) ↓ • Places ID and disease (GC/CT or both) in Microsoft outlook calendar….. 5 weeks from treatment (my automatic reminder)! ↓ 4. 5 weeks later: sends Email to UB account, private Email account or calls cell number (student given choice)…….(Phase 2 improvement) ↓ • If no appointment is made in 5-7 days, only one cell phone call is made! ↓ • Patient returns: Test of re-infection template for providers in EMR 7. TOR lab result tracked and recorded on Excel spreadsheet!..process starts again if TOR+

28. Patient education: Gonorrhea Positive letter

29. Patient Education: Chlamydia positive Letter

30. Template for Email Reminder • Date: • Dear UB student • On 00/00/0000, you tested POSITIVE for a test done at the University at Buffalo Student Health Center and you were treated with medication by medical provider: Name of Provider • This is an important reminder to make a follow-up appointment with a provider for retesting. • The infection that you were treated for can cause infertility if the infection has stayed in your body. • Please call 716-829-3316 and reschedule a follow-up appointment with a provider for TEST OF REINFECTION TESTING. • You need to make this appointment no later than 2 weeks from the date of this e mail.

31. Outcome of Phase 3a. who returned?

32. Outcome Phase 3: positive CT/GC by Ethnicity

33. Breakdown of ideal time frame for Phase 3Ideal time frame 25-55 daysNOTE: all TOR were done within 90 day ideal time frame per CDC

34. Comparison Phase 3 Test of re-infection for Ct/GC: First semester versus Second semester • Was this a “One trick pony”? First semester reported at CDC meeting and poster: 8/13/11 to 12/9/11 with 21 cases Second semester: 1/13/12 to 4/4/12*** 24 cases in that date range **** At least 15 more positive since that date up to 5/14/12.

35. Comments: more Positive outcomes Many other improved outcomes in Phase 3: • Increased staff morale • Patients seem to be better informed – in Phase 1 and 2 many patients returned for testing only because they had s/s of STI again..not one patient did the same in Phase 3..no “repeat offenders”. • Some students (5/41) actually “took charge of their health” and made follow-up appointments for TOR without being called or receiving Email reminder..this is what we strive for! • Patients actually had their contacts (7/41) come in for testing and treatment. • Patients actually must have read educational letter and called or Emailed me if they had medication problems (4/41) or other concerns (2/41). • Decreased missed opportunity – but could improve with “pop up prompts”.

36. Some Negative outcomes • Still 2/41 were positive for CT - issues with long distance relationships • Making follow-up appointment for 6-8 weeks later at end of treatment appointment did not seem to work. Patients advised to do this but > 85% did not! • If follow-up appointment is made, Medicat sends out Email reminder (only to Email address listed in EMR) and free parking pass only 8 hours before appointment! Most patients didn’t even see it.

37. Brief Outline of Phase 3 TOR protocol

38. Can this be duplicated elsewhere? • Yes…with little intervention but you must have team effort! • Team must understand disease $ burden to health care system. They should know the importance of TOR- do “they buy into the changes needed?” • There definitely must be a central way that all + CT/GC are managed → is there established protocols, a CRF, an STD Coordinator and/or a department Champion? a. most established protocols can be “retooled” easily • EMR system would be best for easier access to progress notes, treatment dates, contact info, automatic reminders, follow-ups! templates and prompts help staff • Coordinator should have access to a confidential Excel and/or electronic calendar for reminders.

39. Other points regarding duplication of our success! • I would start in a smaller clinic that has less + STD cases than expand. Flow charts for staff…. • The name and contact information of the Coordinator, who will be contacting the + patient, must be known by the patient. • How the patient wants to receive a reminder must be known by Coordinator. • Staff must realize that “baby steps” can eventually lead to true success but it will take time. Feedback from team needs to be evaluated frequently and protocol “tweaked”.

40. As for Clinic CQI! • This is a perfect example of a process of creating an environment in which management and workers strive to create constantly improving quality! • Found a need • Developed a plan(s) • Looked at results • Continued to improve plan until the goal was reached (improved TOR: baby step approach) Outcome is multifaceted: For the patient: Improved quality of care for patients-hopefully, decreased PID etc. Enhanced client tracking…. For the staff: Improved staff morale Better EMR documentation Team work Continuous review

41. JAMA

42. Questions/ Concerns/ Explanations?